Wednesday, 18 March 2015

[Originally posted on Centre for London blog on 18 March 2015 - I realise I should have been cross-posting, not least to keep a record.]

A devolutionary ‘city deal’ was announced in the budget this morning
for West Yorkshire, adding to those already in place for Glasgow,
Sheffield and Greater Manchester. More are promised, for Cardiff,
Aberdeen, Inverness and Cambridge. But like kids covetously eyeing each
other’s toys, the other cities are asking, ‘How do we get what
Manchester has?’

Manchester (or rather the Greater Manchester Combined Authority,
which will comprise the leaders of the ten Greater Manchester councils,
plus a directly-elected mayor) is setting the standard. It will have
devolved powers over transport, housing, policing and crime, skills,
international promotion and – following a surprise announcement last
month – NHS spending. The Chancellor’s budget added full retention of
growth in business rates (other cities get 50 per cent). Other cities
deals announced so far have been far more modest in scope, covering
skills, specified infrastructure schemes, business support and some
international promotion coordination.

And London is lagging too. The Chancellor’s speech alluded to
announcements about devolved funding for skills, more planning powers
and a London Land Commission, all of which were made last month when the
Mayor and Chancellor launched
their Long Term Economic Plan for London. But neither the Greater
London Authority nor the boroughs have any control over London’s health
service.

To be fair, taking on the NHS in London (which employs 200,000
people, more than the construction industry) could be seen as a poisoned
chalice (eve a hospital pass), as institutions (most recently Barts Health NHS Trust)
teeter on the brink of failure. But the failure to join up health and
social care has become one of the NHS’ big problems, with old people
whose care has been neglected ending up in A&E, and hospital beds
occupied by patients who are ready for discharge, but can’t access
social care services to enable them to leave. The short-term incentives
are to dump costs between local government and the NHS, but both parties
have an interest in tackling a problem that is leading to unnecessary
suffering and huge wastes of money. This may mean some tough choices,
but the past few years have certainly given London local government the
experience it will need in taking tough choices.

So why can’t London look after its own health services? Other cities
have been told that they can’t go ‘The Full Manc’ unless they accept a
directly-elected Mayor rather the relying on a congress of council
leaders (thereby opening a new front in the war of attrition over
elected mayors that has been running for the best part of 20 years). But
London has plenty of mayors: Boris Johnson as Mayor of (Greater)
London, as well as mayors Bullock, Pipe and Wales of Lewisham, Hackney
and Newham respectively.

Perhaps the two-tier local government system makes London too
complex? London certainly is complicated, sometimes Byzantine, though
the Greater London Authority and London councils are working quietly
behind the scenes, including on a shared bid for further devolution. And
in any case, the governance arrangements proposed
for Manchester, which include a Greater Manchester Strategic Health and
Social Care Partnership Board, and a Greater Manchester Joint
Commissioning Board comprising NHS England, clinical commissioning
groups and boroughs, are hardly straightforward.

Perhaps the real problem is one of government, not governance.
Perhaps, as they look over the River at St Thomas’s Hospital, MPs
consider that handing over the NHS in the capital to London’s elected
leaders is a step too far, as is the case with the Met Police. Perhaps,
as in Washington DC, some capital city services are seen as too
important for local accountability.

This fear of letting go should not be determining public policy in
London. But if it is, Londoners may start to wonder whether the presence
of Parliament and Government is a boon to the capital, or a millstone.